Valgus slipped capital femoral epiphysis.

Slipped capital femoral epiphysis (SCFE) is a posteromedial displacement of the epiphysis on the metaphysis. Superolateral displacement of the epiphysis, the valgus SCFE, was first described by Müller, although some authors question its existence. We report 4 additional cases and review the literature regarding valgus SCFE. A retrospective review was performed; the child's sex, race, age, weight and height, symptom duration, type of SCFE (stable/unstable), and slip severity were recorded. There were 105 children (67 boys and 38 girls) with 141 idiopathic SCFEs. Four children were noted to have 7 stable valgus SCFEs. Statistically significant differences between the valgus and varus SCFEs were noted for symptom duration and body mass index, and valgus SCFEs tended to be less severe. When combining the data from the literature and the author's institution, there were 22 children with 30 valgus SCFEs at average age of 12.4 +/- 1.8 years; weight, 69.3 +/- 20.6 kg; height, 155.3 +/- 12.4 cm; and body mass index, 27.l +/- 7.1 kg/cm. The demographics of children with valgus SCFE are similar to children with routine SCFE except for sex: 76% of valgus SCFEs occurred in girls. Awareness of valgus SCFEs is necessary for both diagnosis and treatment. In a "valgus" SCFE, Klein line will always be normal, emphasizing the need for lateral radiographs when evaluating all children for SCFE. Single central screw fixation must be approached with caution because the more medial screw entry point places the screw path in immediate proximity to the femoral neurovascular bundle.

A longitudinal study of patients with multidirectional instability of the shoulder with seven- to ten-year follow-up.

The purpose of our study was to evaluate the long-term outcomes of patients with multidirectional instability of the shoulder initially treated with rehabilitation exercises. Sixty-four patients were treated for atraumatic multidirectional instability of the shoulder between 1987 and 1990. Preliminary evaluation was performed 2 years after initiation of treatment, and final evaluation of the patients was performed at a mean of 8 years after initiation of treatment. At the preliminary evaluation, 5 patients were lost to follow-up. Of the remaining 59 patients, 20 had undergone surgical treatment for stabilization of their shoulder. Of the 39 nonsurgically treated patients, 19 continued to have significant pain, and 18 continued to have significant instability of their shoulder. Of the 59 patients, 28 subjectively rated their shoulder condition as better or much better after conservative treatment. At the final evaluation, 2 more patients were lost to follow-up, and 1 additional patient had had surgical treatment. Thus, of the 57 patients available for final follow-up, 36 had received nonsurgical care, and 21 had undergone surgical treatment. Of the 36 nonsurgically treated patients, 23 rated their shoulders as good or excellent with regard to pain, and 17 were good or excellent with regard to instability. By the modified Rowe grading scale, 5 of 36 patients had excellent results, and 12 had good results. The remaining 19 patients were rated as having poor results. Only 8 patients reported that their shoulders were free of all pain and instability. Overall, of the entire group of 57 patients evaluated between 7 and 10 years after initiation of care, 17 had a satisfactory outcome from nonsurgical management based on stability and Rowe scores, 23 had good or excellent results with regard to pain, and 20 subjectively rated their shoulders as good or excellent. This review revealed a relatively poor response to nonsurgical treatment of multidirectional instability in this population of young, athletic patients.

Factors related to false- versus true-positive neuromonitoring changes in adolescent idiopathic scoliosis surgery.

STUDY DESIGN: A retrospective study of 134 adolescent patients who underwent surgical correction of idiopathic scoliosis between June 1992 and August 1998 was conducted. OBJECTIVE: To examine factors related to changes in somatosensory-evoked potentials with or without neurogenic motor-evoked potentials. SUMMARY OF BACKGROUND DATA: Studies document and demonstrate threshold criteria for changes in neuromonitoring that predict changes in spinal cord function. Rates of false-negative occurrences are low, yet higher rates of false-positive findings may result. METHODS: All the patients had somatosensory monitoring, and 71 patients had both somatosensory-evoked potential and neurogenic motor-evoked potential monitoring. Gender, age, curve types, duration of surgery, type and amount of instrumentation, and amount of correction were examined for their effects on monitoring. Estimated blood volume loss as well as high and low mean arterial pressure and its variance were assessed at the start, middle, and conclusion of the procedure. RESULTS: According to the findings, 122 patients (91%) had no monitoring changes and no postoperative neurologic deficit. Six patients (4.5%) had false-positive readings. Six patients had a postoperative motor or sensory deficit, all of which resolved within 18 months. False-positive readings were associated with greater variability in mean arterial pressure. No consistent predictions could be made about the incidence of cord injury if neuromonitoring changes returned to baseline before the end of surgery. CONCLUSIONS: Questions remain about the predictive accuracy of somatosensory-evoked and neurogenic motor-evoked potentials. According to the findings in this study, in which there were no false-negative readings and a modest false-positive rate, continued use of these methods is recommended. Higher false-positive rates were seen in patients with greater lability in mean arterial pressure. A wake-up test is recommended for all cases in which threshold monitoring changes occur because cases of spinal cord injury may exist even when monitored variables return to baseline.